Midwestern State University Employee Wellness Program
Physical Fitness Readiness Questionnaire
This survey will help you determine if you are ready to participate in a vigorous physical activity program and if you
might benefit from a medical evaluation before starting such a program. For most people physical activity should not
pose any problem or hazard. This questionnaire will help identify those small number of adults for whom vigorous
physical activity might be inappropriate or for those people who should have medical advice about the kinds of
activities or intensity levels most suitable for them. Common sense is the best guide in answering these questions.
Please read each question carefully and check either yes or no for each one.
YES____
NO____
1. Has your doctor ever said you
have heart trouble?
YES____
NO____
2. Have you ever had chest pain or
heavy pressure in your chest as a
result of exercise, walking, or other
physical activity such as climbing a
flight of stairs?
YES____
NO____
3. Do you ever feel faint or
experience severe dizziness?
YES____
NO____
4. Has a doctor ever told you that
you have high blood pressure or
diabetes?
YES____
NO____
5. Have you ever had a real or
expected heart attack or stroke?
YES____
NO____
6. Do you have any physical
condition, impairment or disability,
including any spine, joint or muscle
problems, that should be considered
before you begin an exercise
program?
YES____
NO____
7. Have you ever taken medication
to reduce your blood pressure or your
cholesterol levels?
YES____
NO____
8. Are you excessively overweight?
YES____
NO____
9. Is there any good physical or
medical reason not mentioned here
why you should not follow an
activity program even if you wanted
to?
YES____
NO____
10. Are you over age 35 and not
accustomed to vigorous exercise?
YES____
NO____
11. Are you pregnant?
YES____
NO____
12. Have you ever been diagnosed as
having an eating disorder?
If you answered YES to one or more questions, and if you have not recently done so, consult with your doctor by phone
or in person BEFORE starting an exercise program. Ask your doctor if you may participate in:
1)
Unrestricted physical activity on a gradually increasing basis
OR
2)
Restricted activity to meet your specific needs.
If you answered NO to ALL questions, you have reasonable assurance that you may begin a graduated exercise
program or have an exercise test.